Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Briar Hill Rest Home during CMS and state inspections, most recent first.
Call lights were not kept within reach for multiple residents, including residents in a locked dementia unit. An LPN confirmed several residents’ call lights were out of reach, and in one room the call lights were stuck under a bed and took time and effort to retrieve. The DON, CNA, and Administrator all acknowledged that staff were responsible for ensuring call lights were conveniently placed so residents could summon assistance.
Sharps containers on a locked dementia unit were observed full to the point that they could not be opened, including one in a shower room with three uncapped used disposable razors sitting on top of it and another on a medication cart. The DON and an LPN confirmed the containers were unusable, and the LPN noted two residents on the unit required routine blood glucose monitoring with lancets that would need disposal in a sharps container.
Missing Ombudsman Contact Information: The facility failed to post information for the ombudsman and other pertinent state complaint resources, despite its grievance policy requiring residents to have access to that information. Surveyors observed no ombudsman contact posting in the facility, and the Social Worker confirmed the sign was not in place after it had reportedly been removed for painting and not replaced. Residents raised concerns in council, and one cognitively intact resident reported the poster had been missing for over a month.
CNA staff placed an enteral feeding pump on hold during incontinent care for a resident receiving tube feeding. The CNA later said she turned the pump off in error and acknowledged she was practicing outside her scope, while an LPN and the DON stated CNAs are not authorized or trained to operate feeding pumps and that only licensed nurses may manage them.
Failure to Provide Requested Grooming Assistance: A resident reported that staff were not shaving under her arms in accordance with her preferences, and observation showed thick underarm hair approximately 2.5 inches long. The CNA stated underarm shaving is part of ADLs and important for dignity, and the DON said it is provided by CNAs for hygienic purposes and to maintain dignity. The resident had generalized muscle weakness, other lack of coordination, and moderate cognitive impairment.
A resident with a recent lower leg fracture, assessed as needing a two-person assist for transfers, was injured during a transfer when staff failed to follow the facility's two-person lift protocol. One CNA operated the full body lift while the other was not actively assisting, resulting in the resident sliding from the sling, striking her head, and sustaining a subarachnoid hemorrhage.
The facility failed to maintain sanitary food storage practices, with observations revealing overly ripe produce, outdated milk, and unlabeled food items in the kitchen. The Certified Dietary Manager acknowledged responsibility for checking outdated foods and ensuring proper labeling, while the Administrator expected daily monitoring of food items.
A CNA at an LTC facility recorded and posted a video on social media without a resident's consent, showing an unsafe transfer and making demeaning gestures. The resident, with dementia and cognitive deficits, was unable to consent. The CNA initially denied involvement, but evidence confirmed her identity. The resident's family stated she would not have consented to the video.
A CNA in an LTC facility failed to follow the care plan requiring a two-person transfer for a resident with cognitive deficits and dementia, as shown in a social media video. The facility's policy on safe lifting was not adhered to, leading to the CNA's termination after the incident was reported to the administrator.
The facility did not post direct care daily staffing numbers in an accessible location for residents and visitors on two days during a survey. Despite awareness of the policy by the DON and an LPN, a communication breakdown led to this oversight. The Administrator confirmed the importance of posting staffing information but was unsure why it was not done.
The facility failed to maintain a medication error rate below five percent, resulting in an 11.54% error rate. Two residents were affected due to the unavailability of prescribed medications, which were not reordered in a timely manner. An LPN admitted to forgetting to order one medication stat, and the facility's policy of reordering medications when the supply reached a five-day threshold was not followed.
A facility failed to serve consistent portion sizes as per the menu guidelines, particularly for meatloaf during lunch. A resident, who was cognitively intact and required large portions, reported inconsistent meal sizes. Dietary staff admitted to slicing meatloaf freehand without using available scales, leading to varying portion sizes. The CDM was unaware of the issue, and the Administrator expected adherence to menu portion sizes.
The facility failed to follow care plans for three residents, leading to unsafe transfers and missed medication doses. A resident requiring a two-person assist was transferred by one CNA, while two other residents did not receive prescribed medications due to stock issues. The ADON and DON confirmed the importance of following care plans and medication orders.
Call lights not kept within residents’ reach
Penalty
Summary
The facility failed to ensure residents were provided with reasonable accommodations to maintain a safe and functional environment by not keeping call lights within physical reach for seven of ten sampled residents. During observation, Resident #7 and Resident #10 did not have their call lights within reach. Resident #5 and Resident #8 had call lights out of reach and stuck under Resident #5’s bed, and it took the LPN two minutes and moving the bed several times to retrieve them. Resident #4 and Resident #9 had call lights on the floor under the wall-mounted call light receptacle, and Resident #6’s call light was coiled up on the floor under the receptacle while the resident was resting on the bed. Facility policy stated that all facility personnel must be aware of call lights at all times and that call lights should be placed conveniently for the resident. The DON confirmed that Resident #7’s call light was not within reach and placed it there. The LPN stated he was aware call lights should be in residents’ reach and confirmed he was assigned to the locked dementia unit for the day and that the residents did not have their call lights within reach. The DON, CNA #4, and the Administrator each stated that staff were responsible for ensuring residents had call lights within reach and that call light placement was important for residents to summon assistance as needed.
Sharps Containers Left Full and Unusable
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment for residents by not maintaining sharps containers in a safe manner in two of four observed sharps containers. Record review of the facility’s Sharps Container Policy showed that the facility would use sharps containers for disposal of sharp items, including lancets, and that containers were to be sealed with tape and dated when disposed of, but the policy did not address when or how often the containers should be emptied. During observation, the sharps container in the shower room on the locked dementia unit was full to the point that it could not be opened, and three uncapped used aqua-blue disposable razors were sitting on top of the container. The DON confirmed the container should have been properly disposed of and replaced with a new one and stated the razors on top of the container could pose a potential safety hazard to residents. A second observation showed the sharps container on the medication cart for the locked dementia unit was also full to the point that it could not be opened. An LPN stated the unit had two residents who required routine blood glucose monitoring and that lancets used for blood glucose checks would need to be disposed of in a sharps container, but the container on the medication cart was not usable because it could no longer be opened. The Administrator stated she expected staff to provide for resident safety in the shower room and anywhere sharps containers were located, and confirmed that leaving uncapped or unsheathed disposable razors on top of the sharps container in the shower room could pose a safety hazard for residents.
Missing Ombudsman Contact Information
Penalty
Summary
The facility failed to provide information for pertinent state agencies and advocacy groups, specifically the ombudsman, for two of three days of survey. The facility’s grievance policy stated that residents should have information available on how to file a grievance or complaint, including contact information for the grievance official and independent entities such as the State Survey Agency and the Local Long-Term Care Ombudsman program or protection and advocacy system. However, on 1/20/26 and again on 1/21/26, surveyors observed that there was no information posted displaying the ombudsman’s contact information anywhere in the facility. During an interview on 01/21/2026, the Social Worker provided the ombudsman’s information and stated that the facility had a sign displaying it, but when asked to show it, she took the surveyor to a hallway where the sign normally was and confirmed that no sign was there. She stated that the maintenance supervisor must have removed the sign to paint the wall and had not replaced it. During Resident Council on 1/21/2026, residents voiced concern that the ombudsman poster had been missing for over a month. Resident #1 stated the poster had been missing since the wall painting was completed. Resident #1’s record showed admission with hypothyroidism, and the MDS dated 10/17/25 showed a BIMS score of 15, indicating the resident was cognitively intact.
CNA Operated Enteral Feeding Pump Outside Scope of Practice
Penalty
Summary
The facility failed to ensure that enteral nutrition services were provided in accordance with professional standards of practice and within staff scope of practice for one resident receiving tube feeding. The resident had diagnoses including hemiplegia affecting the left nondominant side and adult failure to thrive, and had an order for Nutren 2.0 via pump at 35 mL per hour with 150 cc water flushes every four hours. The resident’s MDS indicated the resident was rarely understood. During an incontinent check, a CNA placed the feeding pump on hold before checking the resident and left the room to get supplies. The CNA later stated she was allowed to place the pump on hold during incontinent care and that she knew how to put it on hold from watching nurses, but later acknowledged she turned the pump off in error and should not have done so, confirming she was practicing outside her scope. When the CNA returned, the pump was still on hold and beeping, and another CNA told her to get a nurse to stop the alarm. An LPN then entered and placed the pump back on hold, and later stated CNAs are not allowed to operate feeding pumps and are not trained to do so. The DON also stated that only licensed nurses are authorized to operate enteral feeding pumps and that CNAs are expected to notify licensed nursing staff to manage them.
Failure to Provide Requested Grooming Assistance
Penalty
Summary
The facility failed to ensure a resident received necessary grooming assistance in accordance with her preferences. Resident #41 stated that staff do not shave under her arms and reported that, when she lived at home, she shaved under her arms every day or as needed. She said she would be satisfied if staff shaved under her arms at least once a week. During observation, her underarm hair was noted to be thick and approximately 2.5 inches long. Record review showed the resident was admitted on 12/2/25 with diagnoses including generalized muscle weakness and other lack of coordination. Her MDS with an ARD of 1/4/26 showed a BIMS score of 12, indicating moderate cognitive impairment. A CNA stated that shaving under the arms is part of residents' ADLs and is important for dignity and to reflect what residents would typically do at home. The DON also stated that shaving under residents' arms is part of the ADLs provided by CNAs and is performed for hygienic purposes and to maintain residents' dignity.
Failure to Follow Two-Person Lift Protocol Results in Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect during a transfer using a full body lift, resulting in injury. According to facility policy, two staff members are required to operate the total lift, with both present and actively assisting throughout the transfer process. On the day of the incident, one CNA attached the resident to the lift before the second CNA entered the room, contrary to the policy and training that require both staff to be present from the beginning. During the transfer, one CNA turned away to retrieve a geri-chair, leaving the other CNA to operate the lift alone. While the resident was being moved, a loud noise was heard, and the resident began to slide out of the sling, ultimately striking her head and sustaining a bleeding injury. Interviews with staff revealed inconsistent understanding and execution of the two-person assist protocol. The CNAs involved gave differing accounts regarding when the second staff member was present and their roles during the transfer. The lift trainer and DON both confirmed that standard procedure requires both CNAs to be positioned at the lift, with one supporting the resident and the other operating the equipment, to ensure safety. However, during the incident, this protocol was not followed, as one CNA was not actively assisting at the lift when the resident slid out. The resident involved had a recent history of a left lower leg fracture and was assessed as requiring a two-person assist for transfers. Following the incident, the resident was found unresponsive with a head injury and was later diagnosed with a subarachnoid hemorrhage. The failure to follow established transfer protocols directly led to the resident's fall and subsequent injury.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by improper storage and labeling of food items in the kitchen. During an observation, nine overly ripe tomatoes with white biological growth were found in Refrigerator #1. Additionally, an unopened bag of salad mix with a discolored liquid and no manufacturer's date was discovered. An opened block of cream cheese and several plastic storage bags containing sliced ham and bologna were found with handwritten dates, indicating when they were opened. In Refrigerator #3, four containers of chocolate milk were wrapped in plastic wrap with outdated manufacturer's dates. The freezer contained an opened bag of shrimp with exposed contents. Interviews with the Certified Dietary Manager (CDM) and the Administrator revealed acknowledgment of the issues, including overly ripe produce, outdated milk, and unlabeled food items. The CDM admitted responsibility for checking outdated foods and ensuring proper labeling, stating that food should be checked daily and staff are in-serviced monthly on food safety. The Administrator was aware of the findings and expected the kitchen staff to monitor foods daily for expired items and inspect produce regularly.
Resident Exploitation via Social Media Video
Penalty
Summary
The facility failed to protect a resident from exploitation, as evidenced by an incident involving a Certified Nurse Aide (CNA) who recorded and posted a video on social media without the resident's consent. The resident, who had diagnoses of unspecified dementia and cognitive communication deficits, was unable to participate in an interview due to a Brief Interview for Mental Status (BIMS) score of 99. The video showed the CNA forcefully transferring the resident from her bed to a geriatric chair, exposing parts of the resident's body, and making demeaning gestures and comments about the resident's condition. The incident was reported by two CNAs to the facility's Administrator, who then conducted an investigation. The video, which was live-streamed on social media, depicted the CNA dancing and interacting with viewers while the resident was visible in the background. The CNA's actions were praised by viewers, and she responded by clapping and smiling, indicating enjoyment of the attention. The video ended abruptly when the CNA appeared to notice someone approaching the room. Interviews with the involved CNA revealed that she initially denied her involvement in the video, despite evidence from her driver's license photo confirming her identity. The resident's family expressed that the resident was private and would not have consented to such a video. The facility's policies on resident rights and abuse, neglect, and exploitation were reviewed, highlighting the failure to uphold these standards in this incident.
Failure to Ensure Two-Person Transfer for Resident
Penalty
Summary
The facility failed to ensure a two-person transfer for a resident who required extensive assistance, as evidenced by video footage showing a CNA transferring the resident from the bed to a geriatric chair by herself. The facility's policy, which emphasizes the importance of safe lifting and transporting practices to prevent injuries, was not followed. The incident was brought to the attention of the facility's administrator by another CNA who saw the video on social media. The administrator confirmed the incident and subsequently terminated the employment of the CNA involved. The resident involved in the incident was identified as requiring a two-person assist for transfers, as documented in the care plan and confirmed by the MDS nurse and another CNA. The resident's medical history includes a cognitive communication deficit and unspecified dementia, and the resident was unable to participate in interviews due to a BIMS score of 99. The facility's system allows CNAs to access care plans via kiosks, indicating that the CNA should have been aware of the resident's transfer requirements.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to comply with its policy of posting direct care daily staffing numbers in a location accessible to residents and visitors. This deficiency was observed during a survey conducted over three days. On the first two days of the survey, there were no staffing numbers posted in the facility, which was a violation of the facility's policy revised on February 3, 2023. The policy mandates that staffing information be made readily available in a readable format at the beginning of each shift. Interviews conducted with the Director of Nursing and a Licensed Practical Nurse revealed awareness of the requirement to post staffing information. However, there was a breakdown in communication, leading to the failure to post the information on the specified days. The Administrator also acknowledged the policy and its importance but was unsure why the information was not posted during the survey. The usual practice was to post the staffing data at the nursing station, but this was not adhered to on the days in question.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by three errors observed out of twenty-six medication administration opportunities, resulting in an error rate of 11.54%. This affected two residents during medication pass. The facility's policy on medication administration requires medications to be administered as prescribed, but this was not adhered to in the observed cases. For Resident #48, the error involved the unavailability of Bethanechol Chloride, which was not found in the medication cart or the Omnicell. The resident had an active order for this medication, which was not administered for two doses on one day and the morning dose the following day. The LPN responsible admitted to forgetting to order the medication stat, which should have been done to ensure timely administration. Resident #13 experienced a similar issue with the unavailability of Fluticasone Propionate nasal spray and Saline nasal spray. The resident missed doses due to these medications being out of stock. The LPN confirmed the unavailability and reported it to the administration. The facility's policy requires medications to be reordered when the supply reaches a five-day threshold, but this was not followed, leading to the medication errors observed.
Inconsistent Portion Sizes in Meal Service
Penalty
Summary
The facility failed to serve therapeutic portion sizes of food as planned per the facility's menu, specifically for the lunch meal tray line. This deficiency was identified through observation, interviews, and record reviews. The facility's policy on tray assembly, revised in June 2017, requires that prepared foods be portioned and assembled for individual meals with the use of specified serving utensils and portion scales. However, during an observation of the lunch meal, it was noted that the portion sizes for meatloaf were inconsistent. Dietary Staff #1 admitted to slicing the meatloaf freehand, resulting in varying sizes, and confirmed that no means to measure the portions was provided. The Certified Dietary Manager (CDM) was unaware of the uneven slicing and confirmed that a scale was available but not used during the serving of the meatloaf. Resident #40, who was cognitively intact with a BIMS score of 15, had complained about inconsistent portion sizes and had a physician order for a regular diet with large portions. The Administrator was made aware of the issue and expected the dietary staff to adhere to the portion sizes specified on the menu. The facility's failure to provide the necessary tools and oversight to ensure consistent portion sizes led to the deficiency in meeting the nutritional needs of the residents as per the facility's menu guidelines.
Failure to Follow Care Plans and Medication Administration
Penalty
Summary
The facility failed to implement and follow the care plans for three residents, leading to deficiencies in their care. For Resident #12, the care plan required an extensive two-person assist for transfers. However, a CNA was observed transferring the resident alone, which was deemed unsafe and contrary to the care plan. This intervention was crucial for the resident's safety and was documented in the care plan accessible to staff. Resident #13's care plan included medications for managing COPD and respiratory failure, but the necessary nasal sprays were out of stock, resulting in missed doses. Similarly, Resident #48's care plan required Bethanechol Chloride for hypertension, but the medication was unavailable for several doses. The ADON confirmed that medications should be reordered when supplies are low, and the DON emphasized the importance of administering medications as prescribed. These lapses indicate a failure to adhere to the care plans, impacting the residents' health management.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jnh-jaquith Inn | 5 mi | ★★★★★ | 7 | 0 |
| Jnh-jefferson Inn | 5 mi | ★★★★★ | 8 | 0 |
| Jnh-madison Inn | 5 mi | ★★★★★ | 2 | 0 |
| Methodist Sepcialty Care Center | 8.1 mi | ★★★★★ | 1 | 0 |
| Edgewood Health & Rehabilitation | 8.4 mi | ★★★★★ | 9 | 4 |
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